Provider Demographics
NPI:1861704751
Name:CRUM, AMANDA RENAE (OD, MS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:RENAE
Last Name:CRUM
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RENAE
Other - Last Name:MARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD,MS
Mailing Address - Street 1:PO BOX 64481
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4481
Mailing Address - Country:US
Mailing Address - Phone:410-614-5115
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-614-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5961152W00000X
MDTA2276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD049414300Medicaid
MD232148ZALTMedicare PIN